This chapter on the surgical treatment of thyroid disease is both extremely well written and complete with regard to our current approach to well-differentiated thyroid cancer. The management of this disease has certainly changed over the past three to four decades, during which time we have learned more about the biology of this cancer and the fact that microscopic sites of tumour may develop synchronously throughout the gland. Differentiated thyroid cancer, especially papillary tumours, may be multicentric in a majority of patients and, therefore, bilateral lobar extirpation is certainly appropriate. Because of this aggressive approach to well-differentiated thyroid tumour, the technical issues, and especially the important anatomical considerations to avoid injury to the RLN and parathyroid glands, have become especially cogent.
Referencing data from the National Cancer Database, which has been developed by the American College of Surgeons Commission on Cancer in conjunction with the American Cancer Society, the author appropriately notes that total surgical ablation of the thyroid gland has increased over the past 20 years and now represents ~90 % of thyroidectomies for well-differentiated thyroid neoplasms. The experience of the surgeon, as well as the environment in which the surgeon works, seem to have an effect on the aggressiveness of the approach to thyroid cancer, and will obviously have an effect on the overall outcome. Management guidelines have also been developed by the American Thyroid Association and other groups, indicating that a more aggressive approach to well-differentiated thyroid cancer is appropriate.
The technique of total thyroidectomy is of paramount importance and needs to be taught to every young surgeon who does thyroid resections. Injury to the parathyroid glands and RLNs needs to be minimized and, happily, this has occurred in more modern databases of thyroid surgery. Specialization in head and neck surgery, and especially thyroid surgery, has shown that repetitive operations and a higher volume of procedures tend to reduce the likelihood of anatomical injury. Appropriate credentialing and privileging must be mandatory in order to create an environment in which safe thyroid surgery can be performed. This approach will also include appropriate knowledge of the lymph node compartments in the neck, which frequently harbour well-differentiated thyroid carcinoma. Because the central compartment of the neck is a common site of local metastasis, the appropriate technique of dissecting this area is mandatory. The author comments on the technique of performing a bilateral level VI lymph node dissection for papillary thyroid carcinoma and this is certainly becoming more popular worldwide.
Appropriate thyroid surgery begins with good planning by both the surgeon and the operative team. Full disclosure to the patient regarding the potential complications and benefits of the procedure are mandatory. Only then can safe surgical ablation for thyroid cancer be performed.